FILE - In this May 17, 2011 file photo, a section of the Rikers Island prison is seen in New York. In September 2013, a mentally ill New York City inmate named Bradley Ballard died after he was found in his Rikers Island cell naked and covered in feces, with a rubber band tied around his badly infected genitals, after being locked alone in his cell for seven days. Documents obtained by The Associated Press show 39-year-old Bradley Ballard was checked on dozens of times in his cell in September before he was rushed to a hospital. (AP Photo/Seth Wenig, File)

NEW YORK (AP) — After a mentally ill Bradley Ballard made a lewd gesture to a female guard at the Rikers Island jail, he was locked in his cell alone for seven increasingly agitated days in which he was denied some of his medication, clogged his toilet so that it overflowed, stripped off his clothes and tied a rubber band tightly around his genitals.

During that period, guards passed Ballard’s cell in the mental observation unit dozens of times, peering through the window in the steel door but never venturing inside — until it was too late.

The 39-year-old Ballard was eventually found naked and unresponsive on the floor, covered in feces, his genitals swollen and badly infected. He was rushed to a hospital but died hours later.

“He didn’t have to leave this world like that. They could have put him in a mental hospital, got him some treatment,” Ballard’s mother, Beverly Ann Griffin, said from her Houston, Texas, home. “He was a caring young man.”

This December 15, 2010 photo provided by the New York State Department of Correctional Services shows Bradley Ballard in New York. In September of 2014, Ballard, 39, who was mentally ill and an inmate at the Rikers Island jail in New York, died a gruesome death there after being locked alone in his cell for seven days. (AP Photo/New York State Department of Correctional Services)

Ballard’s death last September, detailed in documents obtained by The Associated Press and in interviews with two city officials on condition of anonymity, came five months before another Rikers inmate in a similar mental health unit died in a cell that climbed to a suffocating 101 degrees (38 Celsius) because of malfunctioning heating equipment.

Experts say Ballard’s death is only the latest example of how poorly equipped the city’s jail system is to handle the mentally ill, who make up about 40 percent of the 12,000 inmates in the nation’s most populous city. A third of those inmates suffer from serious mental illnesses such as schizophrenia and bipolar disorder.

In Ballard’s case, his family said he had been diagnosed as schizophrenic more than a decade ago, and he also had diabetes.

Faced with rising criticism over conditions at Rikers, Mayor Bill de Blasio has vowed reforms. Correction Department spokesman Robin Campbell said in a statement Wednesday that Ballard’s case is under investigation. He said mental health and jail officials have started shift-by-shift briefings on inmates like Ballard and are working on other measures “so that a similar tragedy will not happen again.”

Ballard grew up in Houston and moved to New York to pursue a better life after working as a cook in a fried chicken restaurant, his family said. He spent six years behind bars after being arrested in 2004 for assaulting a receptionist and another employee of a New York law firm.

Last June, he was arrested in Houston on public lewdness and assault charges for punching and exposing himself to a bus driver. He was sent back to jail in New York for not telling his parole officer that he had left the city.

He was first placed in a Rikers facility for 17 days, then a Correction Department psychiatric hospital for 38 days. Then he was sent to a mental observation unit at Rikers.

In documents obtained by the AP via a public records request, Cathy Potler, executive director of the city Board of Correction, gave her account of Ballard’s case, based on a review of records, security footage and interviews with inmates.

She noted that though Ballard was in a unit where inmates are ordinarily allowed in and out of their cells to mingle with others for 14 hours a day, he was locked up continuously for seven days and for most of that time wasn’t given his medication.

Guards confined Balllard to his cell on Sept. 4 after he stared for hours at a female officer, rolled up his shirt to look like a penis and thrust it toward her, Potler said.

The next day, Potler wrote, Ballard intentionally flooded his combination sink-toilet, after which a mental health provider spoke with him for 15 seconds through the cell door. The next day, the water to his cell was turned off.

Under city rules, mental health staffers are required to make twice-daily rounds in the unit where Ballard was jailed, and the guards are supposed to be steadily assigned there and receive annual mental health training.

But mental health staffers visited Ballard’s cell only once before he was discovered in distress, according to Potler. Only one of the 53 officers who worked in the unit at the time was a steady, and none had received the required annual refresher course on mental health, Potler wrote.

Jail officers have long complained that they aren’t sufficiently trained to handle severely mentally ill inmates. At a recent public meeting, a union official said trainees get 21.5 hours of mental health training during their 16 weeks of academy instruction, plus the three-hour annual refresher.

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